Measuring Hlth Disp

Nuclear Deterrence

Empl Discr/Affirm Action

Lantos Hearings

Prosecutorial Misconduct

Measuring Health Disparities

(rev. July 16, 2008)

 

A significant portion of the material listed or maintained on the other pages of this site relates to statistical tendencies by which measures of differences between rates at which two groups experience or avoid some outcome are affected by the prevalence of the outcome and the bearing of those tendencies on the evaluation of group differences in the law and the social and medical sciences.  Much of the material on these tendencies concerns the measurement of health and healthcare disparities (or inequalities as they are more commonly termed outside the United States).  The most notable of those tendencies is that when two groups differ in susceptibility to an outcome, the rarer the outcome the greater tends to be the relative difference between rates of experiencing it and the smaller tends to be the relative difference between rates of avoiding it.  Thus, during times of declining mortality and other adverse outcomes, demographic differences in rates of experiencing those outcomes have tended to increase, while demographic differences in rates of avoiding those outcomes have tended to decline.  Yet, almost universally, health disparities research has regarded observed increases in relative differences in mortality as reflecting a meaningful worsening of the relative health of disadvantaged groups without consideration of whether the increases have been greater than, or less than, what would be expected to occur solely because of declining mortality, and without consideration of whether relative differences in survival rates have increased.  Similarly, much has been made of seemingly large disparities within particular settings – e.g., large social gradients in mortality among British civil servants, large racial differences in infant mortality where mothers have high education, and large socioeconomic differences in mortality within relatively egalitarian societies like Norway and Sweden.  It has gone unrecognized that large relative differences in mortality would be expected in such settings simply because mortality is low in those setting.

 

But relative differences in experiencing or avoiding an outcome are not the only measures of differences between the rates of two groups that are affected by the prevalence of an outcome.  In fact, all other measure of differences between the situation of two groups regarding dichotomous variables (e.g., odds ratios, absolute differences, relative indexes of inequality, gini coefficients, longevity differences) also tend to be affected by the prevalence of an outcome.  Hence, it is not clear that there exist tools that can distinguish between changes in rate differences that are solely the result of changes in overall prevalence and those that reflect something of greater consequence.  Most of the material listed below is skeptical as to the prospects for measuring the size of differences in different settings sufficiently reliably to justify the resources devoted to such efforts.  But many of the more recent items address what may be plausible approaches to measuring differences between rates in ways that are unaffected by the prevalence of an outcome.  While these approaches may have serious weaknesses of their own, I maintain that the are clearly superior to the standard practice of appraising he size of differences between rates as if the tendencies discussed above do not exist.

 

Section A, B, and C, list, respectively, publications, conference presentations, and unpublished papers, usually providing links to the material as it is maintained elsewhere on this site.  Section D provides references and links to several score on-line responses to articles in medical or health policy journals addressing health disparities and other measurement issues affected by the above-referenced statistical tendencies.  In each case the response explains the problems with the article as a result of the failure to consider the extent to which observed patterns are consequences of changes in overall prevalence of an outcome.  Most of these that appear on cites of the journal where the article was published are between 400 and 700 words (though the 2008 Pediatrics comment is over 1800 words).  Those appearing on journalreview.org are often four to seven thousand words.  Where it seems useful, parenthetical information may be included in the listing, usually with respect to an item’s addressing some issue other than health disparities.

 

The items in sections A through D are generally listed from most recent to least recent (though in Section D follow-up items are listed with the original item).  For ease of reference, these items are numbered within sections, but, to facilitate updating, are numbered chronologically (that is, from earliest to most recent).  Items in Section D that address statistical issues other than those described in the preceding paragraphs are marked with an asterisk. 

 

The subparts of Section E briefly summarize the following particular issues and, where applicable, identify the references in Sections A through D addressing those issues:  (1) the misinterpretation of health inequalities in the United Kingdom and/or the Whitehall Studies; (2) the misinterpretation of health inequalities in Nordic Countries; (3) absolute differences between rates as a measure of disparities; (4) the approaches to disparities measurement of the National Center for Health Statistics and the Agency for Healthcare Research and Quality; (5) issues regarding health disparities and pay-for-performance; (6) approaches to the measurement of disparities that are unaffected by differences in the overall prevalence of an outcome; (7) scholarly agreement/disagreement with the views expressed in the listed references. 

 

A.        Publications

 

12. Can we actually measure health disparities?  Chance 2006:19(2):47-51:

http://www.jpscanlan.com/images/Can_We_Actually_Measure_Health_Disparities.pdf

 

11. Understanding racial differences in infant morality.  PrenatalEd Update October 2000:

http://www.jpscanlan.com/images/Understanding_Racial_Differences_in_Infant_Mortality.pdf

 

10. Race and mortality.  Society 2000;37(2):19-35 (reprinted in Current 2000 (Feb)):  http://www.jpscanlan.com/images/Race_and_Mortality.pdf

 

9. Both sides misuse data in credit discrimination debate.  American Banker July 22, 1998.

 

8. Mired in numbers.  Legal Times Oct. 12, 1996: http://jpscanlan.com/images/Mired_in_Numbers.pdf

(racial impact of mandatory life sentences)

 

7. When statistics lie. Legal Times Jan. 1, 1996: http://jpscanlan.com/images/When_Statistics_Lie.pdf

(racial disparities in mortgage rejection rates)

 

6. Getting it straight when statistics can lie.  Legal Times Jun 28, 1993: 

http://jpscanlan.com/images/Getting_it_Straight_When_Statistics_Can_Lie.pdf

(age disparities in terminations for failure to meet a performance standard)

 

5. Divining difference. Chance 1994;7(4):38-9,48: http://jpscanlan.com/images/Divining_Difference.pdf

 

4. Comment on “McLanahan, Sorensen, and Watson's 'Sex Differences in Poverty, 1950‑1980.’'"  Signs 1991;16(2):409-13: http://www.jpscanlan.com/images/Signs_Comment.pdf

 

3. The perils of provocative statistics. The Public Interest 1991;102:3 14:

http://jpscanlan.com/images/The_Perils_of_Provocative_Stat.pdf

 

2. An issue of numbers.  The National Law Journal  Mar. 5, 1990:

http://www.jpscanlan.com/images/An_Issue_of_Numbers.pdf

(racial impact of academic eligibility requires, employment discrimination issues)

 

1. The “feminization of poverty” is misunderstood.  The Plain Dealer Nov 11, 1987 (reprinted in Current 1988;302(May):16-18 and Annual Editions: Social Problems 1988/89. Dushkin1988:

http://www.jpscanlan.com/images/Poverty_and_Women.pdf

(feminization of poverty, racial differences in infant mortality rates)

 

B.        Conference Presentations

 

18.  Approaches to Measuring Health Disparities that are Unaffected by the Prevalence of an Outcome, to be presented at American Public Health Association 136th Annual Meeting & Exposition, San Diego, California, Oct. 25-29, 2008.   

 

17.  An Approach to Measuring Differences Between Rates that are not Affected by the Overall Prevalence of an Outcome, to be presented at the British Society for Populations Studies Conference 2008, Manchester, England, Sept. 10-11, 2008. 

 

16.  Evaluating The Sizes Of Differences Between Group Rates In Settings Of Different Overall Prevalence, to be presented at the Joint Statistical Meetings of the American Statistical Association, International Biometric Society, Institute for Mathematical Statistics, and Canadian Statistical Society, Denver, Colorado, Aug. 3-7, 2008. 

15.  Measures of Health Inequalities that are Unaffected by the Prevalence of an Outcome, presented at the 16th Nordic Demographic Symposium, Helsinki, Finland, June 5-7, 2008.

PowerPoint Presentation:  http://jpscanlan.com/images/Scanlan_JP_NDS_Presentation_2R.ppt

14.  Measuring Health Disparities, presented at the Kansas Department of Health and Environment, Center for Health Disparities, 2008 Health Disparities Conference, Topeka, Kansas, Apr. 1, 2008.

 

            PowerPoint Presentation: http://jpscanlan.com/images/KDHE_Presentation.ppt

 

13. Can We Actually Measure Health Disparities?, presented at the 7th International Conference on Health Policy Statistics, Philadelphia, PA, Jan. 17-18, 2008 (invited session).

 

            Abstract: http://www.amstat.org/meetings/ichps/2008/index.cfm?fuseaction=AbstractDetails&AbstractID=300283

            PowerPoint Presentation: http://www.jpscanlan.com/images/2008_ICHPS.ppt

            Oral Presentation:  http://www.jpscanlan.com/images/2008_ICHPS_Oral.pdf

 

 

12.  Measurement Problems in the National Healthcare Disparities Report, presented at American Public Health Association 135th Annual Meeting & Exposition, Washington, DC, Nov. 3-7, 2007.

 

            PowerPoint Presentation:  http://www.jpscanlan.com/images/APHA_2007_Presentation.ppt

            Oral Presentation:  http://www.jpscanlan.com/images/ORAL_ANNOTATED.pdf

            Addendum (March 11, 2008): http://www.jpscanlan.com/images/Addendum.pdf

            Abstract:  http://apha.confex.com/apha/135am/techprogram/paper_153201.htm

           

11. Methodological Issues in Comparing the Size of Differences between Rates of Experiencing or Avoiding an Outcome in Different Settings, presented at the British Society for Populations Studies Conference 2007, St. Andrews, Scotland, Sept. 11-13, 2007. 

            PowerPoint Presentation: http://www.jpscanlan.com/images/2007_BSPS_Presentation.ppt

            Oral Presentation:

            http://www.jpscanlan.com/images/2007_BSPS_Oral_Presentation.pdf

 

10. Approaches to Measuring Differences in Health That Are Unaffected by the Prevalence of an Outcome, Roundtable coffee at 2006 Joint Statistical Meetings of the American Statistical Association, International Biometric Society, Institute for Mathematical Statistics, and Canadian Statistical Society, Salt Lake City, Utah, July 29 – Aug. 2, 2007. 

            Abstract: http://www.amstat.org/meetings/JSM/2007/onlineprogram/index.cfm?fuseaction=abstract_details&abstractid=310293

 

9. Exploring Methods to Measure Health Inequalities that are Unaffected by the Prevalence of an Outcome, presented at Social, Cultural and Economic Determinants of Health: International Perspectives for Global Action (1st  Conference of the Journal Public Health, Journal of the Royal Institute of Public Health), Lisbon, Portugal, May 9-11, 2007.

 

            PowerPoint Presentation:  http://www.jpscanlan.com/images/J_Public_Health_Conf_PowerPoint_Presentation.ppt

            Oral Presentation: http://www.jpscanlan.com/images/Lisbon_Oral_Presentation.pdf

 

 

8. Understanding Variations in Group Differences That are the Results of Variation in the Prevalence of an Outcome,  presented at the American Public Health Association 134th Annual Meeting & Exposition, 2006, Boston, MA, Nov. 4-8, 2006.

 

            Abstract: 

            http://www.jpscanlan.com/images/APHA_Abstract.pdf

            Oral presentation:

            http://www.jpscanlan.com/images/APHA_Oral_Presentation.pdf

            PowerPoint presentation:

            http://www.jpscanlan.com/images/APHA_Presentation.ppt

 

7. The Misinterpretation of Health Inequalities in the United Kingdom, presented at the British Society for Populations Studies Conference 2006, Southampton, England, Sept. 18-20, 2006. 

 

            Oral presentation: 

            http://www.jpscanlan.com/images/BSPS_2006_Oral.pdf

            PowerPoint presentation:

            http://www.jpscanlan.com/images/Scanlan_BSPS_Presentation.ppt

            Complete paper:  http://www.jpscanlan.com/images/BSPS_2006_Complete_Paper.pdf

 

6. Measuring Health Disparities, Roundtable lunch at 2006 Joint Statistical Meetings of the American Statistical Association, International Biometric Society, Institute for Mathematical Statistics, and Canadian Statistical Society. Seattle, Washington, Aug. 6-10, 2006.

5. The Misinterpretation of Health Inequalities in Nordic Countries, presented at: 5th Nordic Health Promotion Research Conference, Esbjerg, Denmark, June 15-17, 2006.

            Abstract: http://www.jpscanlan.com/images/Abstract_-_Misinterpretation_of_Nordic_Health_Inequalities.pdf

            Oral presentation: http://www.jpscanlan.com/images/Esbjerg_Oral.pdf

4. Measuring Health Inequalities, presented at the 5th International Conference on Health Economics, Management and Policy, Athens, Greece, June 5-7, 2006.

            Abstract:  http://www.jpscanlan.com/images/Abstract_-_Measuring_Health_Inequalites.pdf      

            Complete paper:  http://www.jpscanlan.com/images/Measuring_Health_Inequalities.pdf

3. Understanding Increasing Racial Differences in Mortality (and Declining Differences in Survival), presented at the First Annual Health Disparities Conference, Teachers College, Columbia University, New York, New York, Mar. 19, 2006. 

 

2. The Difficulties of Interpreting Changing Racial and Socioeconomic Differences in Health Outcomes," presented at the International Conference on Health Policy Research, Boston, MA, Dec. 9, 2001.

           

            Abstract: http://www.jpscanlan.com/images/Abstract_on_Difficulties.pdf.

 

1. The Misunderstood Relationship Between Declining Mortality and Increasing Racial and Socioeconomic Disparities in Mortality Rates, presented at the conference "Making a Difference:  Is the Health Gap Widening?" sponsored by the Norwegian National Institute of Public Health, Oslo Norway, May 14, 2001.

 

            Abstract:  http://www.jpscanlan.com/images/OSLO_ABSTRACT.pdf

            PowerPoint presentation: http://www.jpscanlan.com/images/Oslo_presentation.ppt

 

C.        Unpublished Papers

 

3. The profiling conundrum. 2001:

            http://www.jpscanlan.com/images/The_Profiling_Conundrum.pdf (concerns the pattern where by the lower the stop rates the greater will tend to be the racial disparity in stop rates)

 

2. Data and discipline.  2000:   

            http://www.jpscanlan.com/images/Data_and_Discipline.pdf

            (concerns the pattern whereby the lower the discipline rate the greater will be the racial difference in discipline rates)

 

1. The relationship between declining mortality and increasing racial and socioeconomic disparities in mortality.  1992: http://www.jpscanlan.com/images/Relationship_Between_Decl_Mort_and_Incr_Disparities.pdf

 

D.        On-Line Responses  

 

59.  Relative differences in outcome rates tend to be large where outcomes are rare.  Journal Review May 31, 2008:  http://journalreview.org/v2/articles/view/15757918.html

 

Responding to:

 

Kawachi I, Daniels N, Robinson DE.  Health disparities by race and class: why both matter.  Health Affairs 2005;24(2):343-352.

 

58.  Identifying meaningful differences in inequalities in revascularization rates in different settings.  Journal Review May 9, 2008: 

http://journalreview.org/v2/articles/view/12594194.html

 

Responding to:

 

Hetemaa T, Keskimäki I, Manderbacka, et al.  How did the recent increase in the supply or coronary operations in Finland affect socioeconomic and gender equity in their use?  J Epidemiol Community Health 2003;57:178-185.

 

 

57.  Health disparities curricula must address measurement issues.  Ann Intern Med May 12, 2008: http://www.annals.org/cgi/eletters/147/9/654

 

Responding to:

 

Smith WR, Betancourt JR, Wynia MK. Recommendations for teaching about racial and ethnic differences in health and health care. Ann Intern Med 2007;147:654-665.

 

 

56.  Study shows different adjustment approaches rather than different relative and absolute perspectives.  Journal Review May 1, 2008: http://journalreview.org/v2/articles/view/17591645.html

Responding to:

Khang YH, Lynch JW, Jung-Choi K, Cho HJ. Explaining age-specific inequalities in mortality from all causes, cardiovascular disease and ischaemic heart disease among South Korean public servants: relative and absolute perspectives. Heart 2008;94:75-82.

 

55.   Understanding patterns of absolute differences in vaccination rates in different settings. Journal Review Apr. 22, 2008:

http://www.journalreview.org/view_pubmed_article.php?pmid=11572737&specialty_id=22&sdesc=&emsg=

 

Responding to:

 

Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM.  Racial disparity in influenza vaccination:  Does managed care narrow the gap between blacks and whites?  JAMA 2001;286:1455-1460.

 

54.  Misinterpreting patterns of relative differences in mortality.  Am J Public Health Apr. 13, 2008:  http://www.ajph.org/cgi/eletters/98/4/699

 

Responding to:

 

Wilkinson RG, Pickett KE.  Income inequality and socioeconomic gradients in mortality. Am J Public Health 2008;98:699-704.

 

53. Comparisons of the sizes of differences between black and white rates for different procedures are not informative without consideration of the overall levels for each procedure. Journal Review Mar. 28, 2008: http://www.journalreview.org/view_pubmed_article.php?pmid=15471775&specialty_id=

 

Responding to:

 

Baicker K, Chandra A, Skinner JS, Wennberg JE.  Who you are and where you live: how race and geography affect the treatment of Medicare beneficiaries.  Health Affairs 2004:Var-33-Var-44.

 

52. Study illustrates ways in which the direction of a change in disparity turns on the measure chosen. Pediatrics Mar. 27, 2008: http://pediatrics.aappublications.org/cgi/eletters/121/3/e547

 

Responding to:

Morita JY, Ramirez E, Trick WE. Effect of school-entry vaccination requirements on racial and ethnic disparities in Hepatitis B immunization coverage among public high school students. Pediatrics 2008;121:e547-e552.

 

51. First learn to measure healthcare disparities.  Health Affairs Mar. 12, 2008: http://content.healthaffairs.org/cgi/eletters/26/3/w405

 

Responding to:

 

Casalino LP, Elster A, Eisenberg A, et al. Will pay-for-performance and quality reporting affect health care disparities? Health Affairs 2007;26(3):405-414.

 

 

50.  Reconsidering a landmark study.  Lancet Feb. 25, 2008: http://www.thelancet.com/journals/lancet/article/PIIS0140673696072261/comments?action=view&totalComments=1

 

Responding to

 

Mackenbach, JP, Kunst, AE, Cavelaars, et al. Socioeconomic inequalities in
morbidity and mortality in western Europe, Lancet 1997; 349: 1655-59.

 

49.  Inclusion of healthcare disparities issues in pay-for-performance programs should await development of reliable means of measuring changes in disparities over time. Journal Review Feb. 16, 2008:

 

http://www.journalreview.org/view_pubmed_article.php?pmid=17426053&specialty_id=0

 

Responding to:

 

Casalino LP, Elster A, Eisenberg A, et al. Will pay-for-performance and quality reporting affect health care disparities? Health Affairs 2007;26(3):405-414.

 

 

48.  Perceptions of changes in healthcare disparities among the elderly dependant on choice of measure,  Journal Review 2/12/08:

http://www.journalreview.org/view_pubmed_article.php?pmid=15451752&specialty_id=0

 

Responding to:

 

Escarce JJ, McGuire TG.  Changes in racial differences in use of medical procedures and diagnostic tests among elderly persons: 1986-1997.  Am J Public Health 2004;94:1795-1799.

 

 

47.  Pay-for-performance and the measurement of healthcare disparities.  Journal Review Feb. 10, 2008:  http://www.journalreview.org/view_pubmed_article.php?pmid=17881629&specialty_id=0

 

Responding to:

 

Chien AT, Chin MH, Davis AM, Casalino LP.  Pay for performance, public reporting, and racial disparities in health car: how are programs being designed.  Med Car Res Rev 2007;64:283S-304S.

 

 

46a.  Implications of the focus on racial/ethnic disparities in control rather than processes in the context of pay-for-performance .  Journal Review Feb. 10, 2008: http://www.journalreview.org/view_pubmed_article.php?pmid=15769766&specialty_id=0

 

Responding to:

 

Follow up on item 46.

 

 

46.  Pay-for-performance implications of the failure to recognize the way changes in prevalence of an outcome affect measures of racial disparities in experiencing the outcome.  Journal Review Feb. 8, 2008: http://www.journalreview.org/view_pubmed_article.php?pmid=15769766&specialty_id=

 

Responding to:

 

Werner, RM, Asch DA, Polsky D. Racial profiling: The unintended consequences of coronary artery bypass graft report cards. Circulation 2005;111:1257–63.

 

 

45.  Comparing health inequalities across time and place with an understanding of the usual correlations between various measures of difference and overall prevalences. Journal Review Jan. 30, 2008:  http://www.journalreview.org/view_pubmed_article.php?pmid=17898027&specialty_id=0

 

Responding to:

 

Moser K, Frost C, Leon D.  Comparing health inequalities across time and place—rate ratios and rate differences lead to different conclusions: analysis of cross-sectional data from 22 countries 1991–200.  Int J Epidemiol 2007;36:1285-1291.

 

 

44.  Increases in relative differences in adverse health outcomes do not necessarily reflect increasing health inequality.  Am J Public Health Jan. 24, 2008: http://www.ajph.org/cgi/eletters/98/2/216

 

Responding to: 

 

Frohlich KL, Potvin L. Transcending the Known in Public Health Practice: The inequality paradox: The population approach and vulnerable populations. Am J Pub Health 2008;98:216-221. 

 

43.  Comparing the size of inequalities in dichotomous measures in light of the standard correlations between such measures and the prevalence of an outcome.  Journal Review Jan. 14, 2008:  http://www.journalreview.org/view_pubmed_article.php?pmid=12850975&specialty_id=

(version with properly formatted tables: http://www.jpscanlan.com/images/Bostrom_and_Rosen_Comment.pdf)

 

Responding to:

 

Boström G, Rosén M.  Measuring social inequalities in health – politics or science?  Scan J Public Health 2003;31:211-215

 

42.  Recognizing the way correlations between improvements in healthcare and reductions in healthcare disparities tend to turn on the choice of disparities measure.  Journal Review Nov. 9, 2007:  http://www.journalreview.org/view_pubmed_article.php?pmid=12597759&specialty_id=22

 

Responding to:

 

Kaytur FA, Clancy CM.  Improving quality and reducing disparities.  JAMA 2003;289:1033-34.

 

41a.  Correction to statements concerning the measurement of healthcare disparities by the Agency for Healthcare Research and Quality in earlier comment on Trivedi et al.  Journal Review Nov. 15, 2007:

http://www.journalreview.org/view_pubmed_article.php?pmid=17062863&specialty_id=

 

Correcting item 41 supra.

 

41.*  Understanding patterns of correlations between plan quality and different measures of healthcare disparities.  Journal Review Aug. 30, 2007:  http://www.journalreview.org/view_pubmed_article.php?pmid=17062863&specialty_id=

 

Responding to:

 

Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ.  Relationship between quality of care and racial disparities in Medicare health plans.  JAMA 2006;296:1998-2004.

 

40a.*  Correction to statements concerning the measurement of healthcare disparities by the Agency for Healthcare Research and Quality in earlier comment on Sequist et al.  Journal Review Nov. 15, 2007:

http://www.journalreview.org/view_pubmed_article.php?pmid=16567608&specialty_id=

 

Correcting item 40 supra.

 

40.  Understanding the ways improvements in quality affect different measures of disparities in healthcare outcomes regardless of meaningful changes in the relationships between two groups’ distributions of factors associated with the outcome.  Journal Review Aug. 30, 2007: http://www.journalreview.org/view_pubmed_article.php?pmid=16567608&specialty_id=

Responding to: 

Sequist TD, Adams AS, Zhang F, Ross-Degnan D, Ayanian JZ. The effect of quality improvement on racial disparities in diabetes care. Arch Intern Med 2006;166:675-681.

39.  Understanding widening socioeconomic differences in child mortality.  Journal Review Aug. 27, 2007, responding to:  http://www.journalreview.org/view_pubmed_article.php?pmid=17666705&specialty_id=

Responding to:

Singh GP, Kogan MD. Widening socioeconomic disparities in US childhood mortality, 1969-2000.  Am J Public Health 2007:97:1658-1665

38.  Interpreting patterns of differing effects of chronic conditions on self-assessed health.  Journal Review June 30, 2007:

http://www.journalreview.org/view_pubmed_article.php?pmid=17395847&specialty_id=0

 

Responding to:

 

Brown AF, Ang A, Pevley AR.  The association between neighborhood characteristics and self-rated health for adults with chronic conditions.  BMJ 2007;97:926-932.

 

37.  Recognizing expected patterns of relative differences in the Whitehall cohort.  Journal Review  June 25, 2007:  http://www.journalreview.org/view_pubmed_article.php?pmid=10746111&specialty_id=

 

Responding to:

 

van Rossum CTM, Shipley MJ, van de Mheen H, et al. Employment grade differences in cause specific mortality. A 25-year follow up of civil servants from the first Whitehall study. J Epidemiol Community Health 2000;54:178-84.

36.  Understanding the way choice of measure tends to dictate the results of studies of the way improvements in healthcare affect disparities.  Journal Review June 19, 2007:  http://www.journalreview.org/view_pubmed_article.php?pmid=17372287&specialty_id=0

 

Responding to:

 

James PD, Wilkins R, Detsky AS, et al. Avoidable mortality by neighborhood income in Canada: 25 years after the establishment of universal health insurance. J Epidemiol Community Health 2007;61:287-296.

35.  Problems with the measurement of changes in health inequalities over time using dichotomous variables and possibilities using continuous variables.  Journal Review  June 19, 2007:  http://www.journalreview.org/view_pubmed_article.php?pmid=12461113&specialty_id=0&sdesc=&emsg=

Responding to:

 

Ferrie JE, Shipley MJ, Davey Smith GD. Change in health inequalities among British civil servants: the Whitehall II study. J Epidemiol Community Health 2002:56:922-926.

 

34.  Recognizing why dichotomous and continuous measures may yield contrary results. BMJ June 11, 2007: http://www.BMJ.com/cgi/eletters/334/7601/990

 

Responding to:

 

Chandola T, Ferrie J, Sacker A, Marmot M.  Social inequalities in self reported health in early old age:  follow-up of prospective cohort study.  BMJ 2007:334:990-996.

 

33.   Recognizing the statistical basis for advances in health care to cause larger relative reductions in mortality in groups with lower base rates.  Journal Review June 9, 2007:  http://www.journalreview.org/view_pubmed_article.php?pmid=17213209&specialty_id=0&sdesc=&emsg=

 

Responding to: 

 

Korda RJ, Butler JRG, Clements MS, Kunitz SJ.  Differential impacts of health care in Australia:  trend analysis of socioeconomic inequalities in avoidable mortality.  Int J Epidemiol 2007;36:157-165.

 

32.  Understanding the ways factors tend to increase outcome rates proportionately more in groups with lower base rates.  Journal Review June 7, 2007: http://www.journalreview.org/view_pubmed_article.php?pmid=15961587&webenv=09GKKkf5b9pWaTHs4MGf2OvAnLdALOmX1q4q4u9CwW5QwVdd9C23MRV3X%401EDE27DE66DB18C0_0029SID&qkey=1&rescnt=3&retstart=0&q=%22thurston+rc%22+%22kawachi+i%22

 

Responding to:

 

Thurston RC, Kubzansky LD, Kawachi I, Berkman LF.  Is the association between socioeconomic position and coronary heart disease stronger in women than in men.  Am J Epidemiol 2005;162:57-64.

 

 

31.  Role of the prevalence of an outcome in the size of rate differences.  J Epidemiol Community Health June 4, 2007:  http://jech.BMJ.com/cgi/eletters/61/6/499

 

Responding to:

 

Martikainen P, Blomgren J, Valkonen T. Change in the total and independent effects of education and occupational social class on mortality: analyses of all Finnish men and women the period 1971-2000. J Epidemiol Community Health 2007;61:499-505.

 

30.  Interpreting departures from expected patterns of relative differences.  J Epidemiol Community Health June 4, 2007: http://jech.BMJ.com/cgi/eletters/57/12/974

 

Responding to:

 

Mustard CA, Etches J. Gender differences in socioeconomic inequality in mortality. J Epidemiol Community Health 2003;57:974-980.

 

29.*   A study with a variety of problems.  Journal Review June 2, 2007:

http://www.journalreview.org/view_pubmed_article.php?pmid=10029647&specialty_id=

 

Responding to:

 

Schulman KA, Berlin JA, Harless, et al.  The effect of race and sex on physicians’ recommendations for cardiac catheterization.  N Engl J Med 1999;340:618-26.

 

28.  Understanding why the accomplishments of the welfare state generally will not reduce health inequalities as they are typically measured.  Journal Review June 2, 2007: http://www.journalreview.org/view_pubmed_article.php?pmid=16735637&specialty_id=

 

Responding to:

Lawlor DA, Ronalds G, Macintyre S, et al.  Family socioeconomic position at birth and future cardiovascular disease risk: findings from the Aberdeen children of the 1950s cohort study. Am J Public Health 2006;96:1271-1277.

27.  Understanding when general increases in an outcome tend to result in increasing absolute differences between the rates of two groups.  Journal Review June 1, 2007: http://www.journalreview.org/view_pubmed_article.php?pmid=16107621&specialty_id=

 

Responding to:

 

Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692-700.

 

26.  Understanding when general increases in an outcome tend to result in increasing absolute differences between the rates of two groups.  Journal Review June 1, 2007: http://www.journalreview.org/view_pubmed_article.php?pmid=16107621&specialty_id=

 

Responding to:

 

Jha AK, Fisher ES, Li Z, Orav EJ, Epstein AM. Racial trends in the use of major procedures among the elderly. N Engl J Med 2005;353:683-691.

 

25.  Understanding expected patterns of changes in absolute differences between the rates at which racial or gender groups receive adequate care.  Journal Review May 1, 2007: 

http://www.journalreview.org/view_pubmed_article.php?pmid=12597751&webenv=0hSY8LIVEtauiykrISC89Xs2x1t6UtSvX_wA54BmpvqtFc-pD_mYOFmuuX%402B600FF566201E70_0043SID&qkey=1&rescnt=6&retstart=0&q=%22sehgal+ar%22+impact

 

Responding to:

 

Sehgal AR. Impact of quality improvement efforts on race and sex disparities   in hemodialysis. JAMA 2003;289:996-1000.

 

24.       Recognizing the role of the prevalence of an outcome in comparing the size of relative differences in experiencing or failing to experience the outcome.  Journal Review  May 31, 2007:

http://www.journalreview.org/view_pubmed_article.php?pmid=10882763&webenv=0aoJ5mGfxigOPFhKrRoFZMOOpA0kPxYLWamclX0JZD4SRW9Yz-ZAu4AUdt%402B6007EE661FED70_0024SID&qkey=1&rescnt=1&retstart=0&q=%22gan+sc%22+%22beaver+sk%22

 

Responding to:

 

Gan SC, Beaver SK, Houck PM, et al.  Treatment of acute myocardial infarction and 30-day mortality among women and men.  N Engl J Med 2000;343:8-15.

 

 

23a.*  Correction to statements concerning the measurement of healthcare disparities in the National Healthcare Disparities Reports in earlier comment on Vaccarino et al.  Journal Review Nov. 6, 2007:   http://www.journalreview.org/view_pubmed_article.php?pmid=16107620&specialty_id=

 

Correcting no. 23 supra.

 

23.       Effects of choice measure on determination of whether health care disparities are increasing or decreasing.  Journal Review  May 1, 2007: http://www.journalreview.org/view_pubmed_article.php?pmid=16107620&webenv=00P_2r_lHBKZPkExnEkCR_j5-u8waNcJ-87aLnoSJWxvN_ljFKstOR3CAx%402B600907661FF950_0034SID&qkey=1&rescnt=2&retstart=0&q=%22vaccarino+v%22+%22rathore+ss%22

(see correction at 23a)

 

Responding to:

 

Vaccarino V, Rathore SS, Wenger NK, et al. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. N Engl J Med 2005;353:671-682;
                       
Jha AK, Fisher ES, Li Z, Orav EJ, Epstein AM.
Racial trends in the use of major procedures among the elderly. N Engl J Med 2005;353:683-691; and

Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692-700.


22.   Understanding why reductions in injury rates will tend to increase relative differences in injury rates.  Lancet Jan. 31, 2007: http://www.theLancet.com/journals/Lancet/article/PIIS0140673606688958/comments?action=view&totalComments=1

Responding to:

 

Sethi D, Racioppi F, Baumgarten I, Bertollini R. Reducing inequalities from injuries in Europe. Lancet 2006:368:2243-50.

 

21. Interpreting changes in relative inequalities in receipt of procedures. J Epidemiol Community Health Jan 25, 2007.  http://jech.BMJ.com/cgi/eletters/57/3/178

 

Responding to:

 

Hetemaa T, Keskimäki I, Manderbacka, et al. How did the recent increase in the supply or coronary operations in Finland affect socioeconomic and gender equity in their use? J Epidemiol Community Health 2003;57:178-185.

 

19.   The relationship between the prevalence of an outcome and the size of the relative disparity in experiencing it.  BMJ  Dec 14, 2006: http://www.BMJ.com/cgi/eletters/333/7579/1177.

Responding to:

Kristensen P. Review of Social Inequalities in Health: New Evidence and Policy Implications. BMJ 2006;333:1167.

18.  Issue in the interpretation of health inequalities in New York.  J Epidemiol Community Health Dec. 14, 2006: http://jech.BMJ.com/cgi/eletters/60/12/1060

 

 

Responding to:

 

Karpati AM, Bassett MT, McCord C. Neighborhood mortality inequalities in New York City, 1989-1991 and 1999-2001. J Epidemiol Community Health 2006;60:1060-1064.

 

17.  Why we should expect Nordic countries to show large relative socioeconomic inequalities in mortality.  Lancet Oct. 7, 2006:

http://www.theLancet.com/journals/Lancet/article/PIIS0140673606695019/comments?action=view&totalComments=1

 

Responding to:

 

Wilkinson R. The politics of health. Lancet 2006;368:1229-1230.

 

16.  Explanation for large health inequalities in Nordic countries.  Eur J Public Health  Nov. 1, 2006:  http://eurpub.oxfordjournals.org/cgi/eletters/15/5/518#22

Responding to:

Hemmingsson T, Lundberg I. Can large relative mortality differences between socioeconomic groups among Swedish men be explained by risk indicator-associated social mobility? Eur J Public Health 200515:518 -522.

15.    Differences in comparing relative differences across subgroups.  J Epidemiol Community Health Dec. 4, 2006: http://jech.BMJjournals.com/cgi/eletters/60/9/760

 

Responding to:

 

Kaplan RM, Kronick RG. Marital status and longevity in the United States Population. J Epidemiol Community Health 2006;60:760-765.

 

14.  Differences in average hospital stay as a measure of inequality.  Am J Public Health Aug. 18, 2006: http://www.ajph.org/cgi/eletters/AJPH.2005.063339v1

 

Responding to:

 

Icks A, Haastert B, Rathmann W, et al. Trends in hospitalization and sociodemographic factors in diabetic and nondiabetic populations in Germany: National Health Survey, 1990-1992 and 1998. Am J Public Health 2006;96:1656-1661.

 

13.  Understanding inequalities in injury deaths.  BMJ  July 19, 2006: http://BMJ.BMJjournals.com/cgi/eletters/333/7559/119

 

Responding to: 

 

Edwards P, Green J, Roberts I, Lutchmun S. Deaths from injury in children and employment status in family: analysis of trends in class specific death rates. BMJ 2006;333:119-121.

 

12.  Understanding how changes in prevalence of adverse health outcomes affect health inequalities.  Lancet  May 23, 2006: http://www.theLancet.com/journals/Lancet/article/PIIS0140673606684894/comments?action=view&totalComments=1

 

Responding to:

 

Wilkinson R, Pickett K. Health inequalities and the UK Presidency of the EU. Lancet 2006;376:1126-1128.

 

11.*  Understanding social gradients in adverse health outcomes within high and low risk populations.  J Epidemiol Community Health May 18, 2006: http://jech.BMJjournals.com/cgi/eletters/60/5/436

 

Responding to: 

 

Lynch J, Davey Smith G, Harper S, Bainbridge K. Explaining the social gradient in coronary heart disease: comparing relative and absolute risk approaches. J Epidemiol Community Health 2006:60:436-441.

 

10.  Changing inequalities in morbidity.  J Epidemiol Community Health May 16, 2006: http://jech.BMJjournals.com/cgi/eletters/60/3/218

 

 

Responding to: 

 

Adams J, Holland L, White M. Changes in socioeconomic inequalities in census measures of health in England and Wales, 1991-2001. J Epidemiol Community Health 2006;60:218-222.

 

9.  Re: Relative measures have limitations too.  BMJ  May 16, 2006: http://BMJ.BMJjournals.com/cgi/eletters/332/7547/967

 

Responding to authors’ reply to item 8.

 

8.         Problems with relative measures of health inequalities.  BMJ  May 8, 2006: http://BMJ.BMJjournals.com/cgi/eletters/332/7547/967

 

Responding to:

 

Low A, Low A. Importance of relative measures in policy on health inequalities. BMJ. 2006;332:967-969.

 

7.  Interpreting increasing health inequalities in Spain.  Am J Public Health Apr. 24, 2006: http://www.ajph.org/cgi/eletters/96/1/102

 

Responding to: 

 

Regidor E, Ronda E, Pascual C, Martinez D, Calle ME, Dominguez V. Decreasing socioeconomic inequalities and increasing health inequalities in Spain: A case study. Am J Public Health 2006;96:102-108

 

6.  Measuring health disparities. J Public Health Manag Pract 2006;12(3):293-296: http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=641470

 

 

Responding to:

 

Keppel KG, Pearcy JN. Measuring relative disparities in terms of adverse events. J Public Health Manag Pract 2005;11(6):479–483.

 

5.  Difficulties in the interpretation of patterns of health racial differences in allostatic load.  BMJ  Feb. 26, 2006: http://www.ajph.org/cgi/eletters/96/5/826   (In second sentence of second paragraph, “more prevalent” should be “less prevalent.”)

 

Responding to:

 

Geronimus A, Hicken M, Keene D, and Bound J. Weathering and Age Patterns of Allostatic Load Scores Among Blacks and Whites in the United States. Am J Public Health 2006;96:826-833.

 

4.  Interpreting trends in racial disparities in stillbirth.  Am J Public Health Feb. 26, 2006: http://www.ajph.org/cgi/eletters/95/12/2213

 

Responding to:

 

Ananth CV, Shiliang L, Kinzler WL, Kramer MS. Stillbirths in the United States, 1981-2000: An Age, Period and Cohort Analysis. Am J Public Health 2005;95:2213-2217.

 

3.  Changing social inequalities in SIDS.  Am J Public Health  Dec. 11, 2005: http://www.ajph.org/cgi/eletters/95/11/1976

 

Responding to:  

 

Pickett et al. Widening social inequalities in risk for sudden infant death syndrome. Am J Public Health 2005;95:97-81.

 

2..  Interpreting changes in mortality differences.  J Epidemiol Community Health  Sep. 8, 2005: http://jech.BMJ.com/cgi/eletters/59/8/638

 

Responding to:

 

Shaw C., Blakely T., Atkinson J., Crampton P. Do social and economic reforms change socioeconomic inequalities in child mortality?  A case study: New Zealand, 1981-1999.  J Epidemiol Community Health 2005;59:638-644.

 

1.  Appraising the size of racial differences in mortality.  Health Affairs Aug. 23, 2005: http://content.healthaffairs.org/cgi/eletters/24/2/459

 

Responding to:

 

Satcher D., Fryer G.E., McCann J., et al.  What if we were equal?  A comparison of the black-white mortality gap in 1960 and 2000.  Health Affairs 2005;24(2):459-564.

 

E.         Summaries of Particular Issues

 

1. Health Inequalities in the United Kingdom 

 

For three decades, the United Kingdom has been a leader in health inequalities research, and the Whitehall Studies have played a significant role in such research.  In the main, such research has relied on relative differences in adverse outcomes and has interpreted increasing relative differences in mortality as reflecting increasing health inequality without regard to the extent to which increases in relative differences in mortality are a statistical function of declining mortality or whether relative differences in survival rates have declined.  That relative differences in mortality are larger among British civil servants than in UK society at large has been the basis for a number of inferences about the causes or nature of health inequalities.  For example, such fact has been interpreted to suggest that health inequalities in the UK population at large are greater than they seem.  It has also been interpreted to suggest that psycho-social factors play as large a role in health inequalities as material circumstances.  But such interpretations have been reached without consideration of the extent to which large relative inequalities in mortality (or small relative differences in survival) among British civil servants are a function of the low mortality in that population. These and related issues are addressed in references B3, D8-D10, D12,D13, D20, D28, D32, D34, D35, D37

 

2. Seemingly Large Health Inequalities in Nordic Countries

 

In 1997 a landmark study in The Lancet surprised many by finding that the comparatively egalitarian countries of Sweden and Norway had larger than average relative differences in mortality.  Such finding would be repeatedly noted in ensuing years and may well have increased within Nordic countries interest in the study of health inequalities.  But the Lancet article overlooked the role of low mortality in large relative differences in mortality in countries like Norway and Sweden.  These issues are discussed generally in references A12, B3, B5, D16, D17, D19, D50, and D54.  References D50 and D54 also discuss a 2007 article co-authored by two of the principal authors of the Lancet study. The 2007 article reaches conclusions about the systematic relationship between relative differences in an outcome and the prevalence of an outcome that also call into question the conclusions of the Lancet article.  See also Section E.7.

 

Reference B3 (at 13-14) discusses the implications of absolute minimums in the context of a situation, such as that in Sweden, with extremely low infant mortality.  References D20 and D31 also discuss certain health inequalities issues involving Finland, but not with regard to issues that are peculiarly germane to Nordic countries,

 

3. Absolute Differences and Odds Ratio

 

Most of the earlier references listed on this page principally or exclusive discuss the correlations between overall prevalence of an outcome and relative differences in experiencing or avoiding it.  The reasoning of those references, however, would also lead to certain conclusions about the way absolute differences and odds ratios are correlated with overall prevalence, as discussed in a couple of earlier works (A3 (1991), C1 (1992)).  Such pattern, roughly, is that absolute differences tend to be small when an outcome is rare, grow larger as it becomes more common, and then grow small again as it becomes nearly universal; differences measured in odds ratios behave in the opposite manner.  Beginning with B2 (2001) and B3 (2001), the listed references give increasing attention to absolute differences and odds ratios, including A12, B4-B14, and D2, D6-D9, D15, D17, D18, D20, D23, D25-D27, D30, D31, D33-D36, D38, D40-D42, D 47, D53, D55.  The more recent references, particular the conference presentations from B11 on and D23, D40, D41 give a good deal of attention to the point at which the direction of changes in absolute differences reverse as an outcome becomes more common and the implications of that point with respect to the interpretation of changes in healthcare disparities over time and the correlation of the quality of health care with absolute differences.

 

4. Health and Healthcare Disparities Measurement Approaches of the National Center for Health Statistics and Agency for Healthcare Research and Quality

The 2000 article Race and Mortality (item A12) principally discussed the way relative differences in adverse health outcomes tend to be larger (and relative differences in the opposite outcome tend to be smaller) where the adverse health outcomes are rarer.  But the article also pointed out that, solely as a matter of convention, disparities in things like beneficial healthcare procedures were typically measured in terms of relative differences in rates of receiving such procedures. Thus, it noted, since such procedures were becoming more widespread, racial disparities in those outcomes were perceived to be declining.  Responding to Race and Mortality (and A5), in 2004 and 2005 statisticians at the National Center for Health Statistics (NCHS) published a number of reports or articles recommending that all disparities (both with regard to health and healthcare) be measured in terms of relative differences in adverse outcomes (in the case of healthcare, the failure to receive appropriate healthcare).  Such is the approach used to measure progress in eliminating disparities for purposes of Health People 2010.  The Agency for Healthcare Research and Quality (AHRQ), which issues the yearly National Healthcare Disparities Report, measures disparities in terms of the larger of the relative difference in the favorable or the adverse outcome. Since the latter relative difference is almost always larger than the former for the things that AHRQ examines, its approach is usually consistent with that of NCHS.

A number of the references on this page criticize NCHS and AHRQ for the failure to recognize or address the correlation between prevalence of an outcome and relative differences in experiencing or avoiding it.  These references also point out that the consequence of the usual approach of NCHS and AHRQ is to find improvement of healthcare to be correlated with increasing healthcare disparities as NCHS (always) and AHRQ (usually) measure them.  See A12, B3, B12, B13, D12, D23a, D40, D40a, D41, D41a, D52, D53, D55.  The Addendum to B12 and D52 also discuss the situations where the AHRQ approach would lead to reliance on the relative differences in the favorable outcome at one point in time and the relative difference in the adverse outcome at another point in time.  See also Section E.7.

5. Pay-for-Performance Issues

Relying on absolute differences between rates, the 2005 article to which reference D46 responds found that coronary artery bypass report cards tended to increase racial disparities in bypass grafts, measured in terms of absolute differences between rates.  Such finding has been interpreted as suggesting that pay-for-performance programs may increase racial disparities in healthcare and have led to suggestions that effects on healthcare disparities be part of pay-for-performance programs, something now being implemented in Massachusetts.  A number of the references listed in Section D argue that the finding that coronary artery bypass report card grafts increase racial disparities was flawed for failure to recognize that, solely for statistical reasons, increases in availability of coronary artery bypasses would tend to increase absolute differences between rates bypass rates.  Apart from questioning this finding, references D46, D46a, D47, D49, and D51 raise questions about including effects on healthcare disparities in pay-for-performance programs, given that near universal lack of understanding of the relationship of the prevalence of an outcome to each measure of health disparities and the difficulty, even with such an understanding, of reliably measuring changes in disparities over time. 

6. Measures of Health and Healthcare Disparities that are Unaffected by the Prevalence of an Outcome

 

A number of the references on this page (e.g., A12, B3), in addition to describing the problems with the standard measure of health disparities, raise issues about whether, with regard to the crucial appraisal of the comparative size of disparities in different settings (particularly at different points in time), disparities can be measured reliably enough to justify the amount of research conducted in this area.  Several items (e.g., B3, B9-B11)) explore the possibility of using genuinely continuous measures, assuming that they do not raise the same issues as binary measures, and in doing so, explain why many seemingly continuous measures are in fact functions of dichotomies and hence implicate the same interpretive issues as binary measures.  A number of more recent works (B13-B15, D43, D45, D46, D46a, D48, D52, D53, D55), however, explore the possibility of measuring the size of disparities in particular settings by deriving, from the rates of the advantaged and disadvantaged groups being compared in each setting, the size of the difference between means of hypothesized underlying distributions (measured in terms of percentage of a standard deviation).   As repeatedly noted in those works (and as explored at greatest length in Section B of reference 43), this approach involves some speculation, given that we do not know what the underlying distributions actually look like.  And, as discussed in references 43 and D46a, the approach appears not to be even theoretically sound as to situations where we know the distributions are not normal because they are in fact truncated portions or larger distributions.  Nevertheless, an approach along these lines is superior to anything else currently employed and, at a minimum, provides a basis for appraising the plausibility of conclusions reached through other methods.

 

Inasmuch as most of the D references contain a good deal of narrative material that, while not without value, may discourage some readers, links to the tables illustrating the approach in most of the D references are set out below:

 

http://www.jpscanlan.com/images/Tables_for_Comment_on_Moser.pdf

http://www.jpscanlan.com/images/Escarce_table.pdf

http://www.jpscanlan.com/images/Table_A_to_Baicker_Comment.pdf

http://www.jpscanlan.com/images/Tables_A_and_B_to_Morita_Comment.pdf

http://www.jpscanlan.com/images/Khang_Tables_A_and_B.pdf

http://www.jpscanlan.com/images/Schneider_comment_table.pdf

http://www.jpscanlan.com/images/Hetemaa_Tables.pdf

http://www.jpscanlan.com/images/Geronimus_Table_A.pdf

 

 

7.  Consensus with Views Expressed on this Page

 

The references listed on this page take for granted that the views as to the correlations between prevalence of an outcome and binary measures of difference are correct.  Not everyone may share that view.  Discussed below are the ways some researchers have reacted to these views.

 

As discussed in Section E.4, the NCHS responded to reference A12 and A5 by recommending that all disparities be measured in terms of relative differences in adverse outcome.  In doing so, however, NCHS never acknowledged that those references did not merely show situations where relative differences in experiencing an outcome and relative differences in avoiding the outcome changed in opposite directions as the prevalence of an outcome changed, but maintained that such pattern was systematic.  See, e.g., D6.  On the panel at the 7th International Conference on Health Policy Statistics at which reference B13 was presented, Kenneth G. Keppel, the principal author of the NCHS position (in presenting item a below), expressed the view that the points expressed in B13, while correct with respect to cross-sectional data, were not correct with respect to longitudinal data, observing that patterns observed over time are not the same as those observed with the lowering of a cutoff.  In my view, while patterns observed over time will rarely if ever be precisely those illustrated by the lowering of a cutoff, they will almost invariably exhibit similar tendencies.  And it makes no sense to make comparisons over time without consideration of such tendencies. 

 

Relying on a 2001 presentation on these issues in Oslo (B1), Carr-Hill and Chalmers-Dixon (item b below) (at 171-72), explicitly accepted the reasoning of that presentation with regard to relative differences.  But the lengthy document, which discusses a variety of health disparities issues and measurement techniques, gives no indication of recognizing the implications of such acceptance as to other measures it discusses.  In my view, the acceptance calls into question much of the reasoning in the remainder of the document.  For the patterns described here affect each of the measures discussed in the Carr-Hill/Chalmers-Dixon document.

 

A 2007 article by Houweling et al. (item c below) is article mentioned in Section E.2 as one co-authored by two authors of the 1997 Lancet and that calls the conclusions of the Lancet article into question.  The Houweling article in part a response to Race and Mortality and questions Race and Mortality for overstating the force of the tendencies it describes.  The Houweling article ignores entirely Race and Mortality’s discussion as to why certain patterns will tend to be observed and why in some cases they will tend not to be observed.  But the Houweling article nevertheless finds systematic correlations between the prevalence of an outcome and relative differences in experiencing it and avoiding it that are the same as those described in Race and Mortality.  The Houweling article also finds systematic correlations between the absolute differences and the prevalence of an outcome according to the same reverse U-shaped pattern illustrated or described in the references listed in Section E.3.  But the Houweling article suggests that the odds ratio would avoid the problems arising from the correlations it describes.  In my view, as discussed in the Section E.3 references, the odds ratio does not avoid such problems, because differences measured in odds ratios are also correlated with the prevalence of an outcome.  Also in my view, the explanations offered for the observed patterns are less sound than those described in Race and Mortality and many other places listed on this page.  But, as with my works, the Houweling article also calls into question the validity of the overwhelming majority of health disparities research to date.

 

Items by other authors referenced in Section E.7 are:

 

a. Keppel KG.  Measuring Disparities in Health People 2010, presented at the 7th International presented at the 7th International Conference on Health Policy Statistics, Philadelphia, PA, Jan. 17-18, 2008 (invited session).

 

b. Carr-Hill R, Chalmers-Dixon P. The Public Health Observatory Handbook of Health Inequalities Measurement. Oxford: SEPHO; 2005: http://www.sepho.org.uk/extras/rch_handbook.aspx

c. Houweling TAJ, Kunst AE, Huisman M, Mackenbach JP.  Using relative and absolute measures for monitoring health inequalities: experiences from cross-national analyses on maternal and child health.  International Journal for Equity in Health 2007;6:15: http://www.equityhealthj.com/content/6/1/15